NCC215669_FRO Submitted_20211014

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Sanitary Sewer Trunk The Courtyards on Lawyers Road
2. Location of land -disturbing activity: CountyUnion City or Township Stallings
Highway/Street Lawyers Road Latitude 35 08' 32.67 ' N Longitude -80 37' 19.52 'W
3. Approximate date land -disturbing activity will commence: May 1st, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.88 Ac.
6. Amount of fee enclosed: $ 135.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed x
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Davis — E-mail Address [e-mail]
Telephone Cell # 704-589-4821 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Brooke Drew Ventures, LLC.
Name Telephone Fax Number
P.O. Box 691287 14617 Lawyers Road, Suite A
Current Mailing Address Current Street Address
Charlotte NC 28227 Matthews NC 28104
City State Zip City State Zip
10. Deed Book No. 5569 Page No. 390 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
EPCON COMMUNTIES [e-mail] _
Name E-mail Address
500 Stone Henge Parkway 500 Stone Henge Parkway
Current Mailing Address Current Street Address
Dublin, Ohio 43017 Dublin, Ohio 43017
City State Zip City State Zip
Telephone [phone] Fax Number NA

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name
N/A
Current Mailing Address
N/A
City State
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City State Zip
Fax Number N/A
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
NA
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Bob Kardos
Type or
Signature
Regional President, Epcon Communities
Title or Authority
AI 2I it Z 2v
Date
1, Angelia B. Dunlan_ , a Notary Public of the County of __Mecklenburg
State of North Carolina, hereby certify that Bob Kardos appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this I,-5- To
of April. , 20_0 _
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My commission expires 4/11/2023